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	<form name="formCNTV" id="formCNTV" method="post" action="..//radicacionWeb/radicacionPqrs/radicarSugerenciaP.php">
	
    <table width="985" align="center"  id="tblSolicitarInfo" cellpadding="0" cellspacing="0" bgcolor="#FFFFFF">
    <tr align="center">
    <td width="10" background="Imagenes/line_fondo.jpg">&nbsp;</td>
    	<td align="justify" colspan="3">Por favor llene el siguiente formulario con sus datos para guardar sus comentarios, en la Comisi&oacute;n Nacional de Televisi&oacute;n nos interesa su opini&oacute;n.</p>
      <blockquote><blockquote>  <p style="color:#FF0000; font-family:Tahoma; font-size:14px">Los campos marcados con (*) son obligatorios.</blockquote></p></td>
     <td width="10" background="Imagenes/line_fondo_1.jpg">&nbsp;
	 
	 </td>
    </tr>
    
    <tr>
    	<td width="10" background="Imagenes/line_fondo.jpg">&nbsp;</td>
    	<td width="250" "></td>
    	<td  valign="top" align="left" width="25%">
		<p style="color:#555555; font-family:Tahoma; font-size:14px">(*)Nombres:</p>
  		</td>
        
    	<td class="dr">
        <input name="nombre_us1" id="nombre_us1" class="celda" type="text" value="" onblur="aMayusculas(this.value,this.id)" />
       <script>var f4 = new LiveValidation('nombre_us1');
			f4.add( Validate.Length, { minimum: 5 } );
			f4.add( Validate.Presence ,{failureMessage: "Campo Obligatorio" });
			</script>
    <td width="10" background="Imagenes/line_fondo_1.jpg">&nbsp;</td>
    </tr>
    
    
    
    
    <tr>
    <td width="10" background="Imagenes/line_fondo.jpg">&nbsp;</td>
    <td width="250" "></td>
    	<td  valign="top" align="left">
        <p style="color:#555555; font-family:Tahoma; font-size:14px">(*)Primer Apellido:</p>
    	</td>
        
    	<td>
        <input name="prim_apel_us1" id="prim_apel_us1" class="celda" type="text"  value="" onblur="aMayusculas(this.value,this.id)" />
        <script>var f4 = new LiveValidation('prim_apel_us1');
			f4.add( Validate.Length, { minimum: 5 } );
			f4.add( Validate.Presence ,{failureMessage: "Campo Obligatorio" });</script>
          
    	</td>
            <td width="10" background="Imagenes/line_fondo_1.jpg">&nbsp;</td>
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    <tr>
    <td width="10" background="Imagenes/line_fondo.jpg">&nbsp;</td>
    <td width="250" "></td>
    	<td  valign="top" align="left">
        <p style="color:#555555; font-family:Tahoma; font-size:14px">(*)Segundo Apellido:</p>
    	</td>
        
    	<td>
        <input name="seg_apel_us1" id="seg_apel_us1" class="celda" type="text"  value="" onblur="aMayusculas(this.value,this.id)" />
          <script>var f5 = new LiveValidation('seg_apel_us1');
			f5.add( Validate.Length, { minimum: 5 } );
			f5.add( Validate.Presence ,{failureMessage: "Campo Obligatorio" });</script>
    	</td>
            <td width="10" background="Imagenes/line_fondo_1.jpg">&nbsp;</td>
    </tr>
    <tr>
    <td width="10" background="Imagenes/line_fondo.jpg">&nbsp;</td>
    <td width="250" "></td>
    	<td valign="top" align="left">
        <p style="color:#555555; font-family:Tahoma; font-size:14px">(*)Tipo de Documento:</p>
    	</td>
        
    	<td>
        <select id="tipoCedula" name="tipoCedula" class="celda" style="font-family:Tahoma; font-size:14px">
			<option value="none" style="font-family:Tahoma; font-size:14px">Seleccione...</option>;
        	<option value="cc" style="font-family:Tahoma; font-size:14px">Cedula de Ciudadan&iacute;a</option>
        	<option value="ce" style="font-family:Tahoma; font-size:14px">Cedula de Extranjer&iacute;a</option>
        	<option value="nit" style="font-family:Tahoma; font-size:14px">NIT</option>
			<option value="ti" style="font-family:Tahoma; font-size:14px">Tarjeta de Identidad</option>
        <?php
			if(isset($_POST['tipoCedula']) != ""){
        		if($_POST['tipoCedula'] == "none"){
					echo '<option value="none" style="font-family:Tahoma; font-size:14px" selected ="true">Seleccione...</option>';
				}else if($_POST['tipoCedula'] == "cc"){
					echo '<option value="cc" style="font-family:Tahoma; font-size:14px" selected="true">Cedula de Ciudadan&iacute;a</option>';
				}else if($_POST['tipoCedula'] == "ce"){
	        		echo '<option value="ce" style="font-family:Tahoma; font-size:14px" selected = "true">Cedula de Extranger&iacute;a</option>';
				}else if($_POST['tipoCedula'] == "nit"){
					echo '<option value="nit" style="font-family:Tahoma; font-size:14px" selected="true">NIT</option>';
				}else if($_POST['tipoCedula'] == "ti"){
	        		echo '<option value="ti" style="font-family:Tahoma; font-size:14px" selected="true">Tarjeta de Identidad</option>';
				}
	
			}
		?>
        </select>
    	</td>
        <td width="10" background="Imagenes/line_fondo_1.jpg">&nbsp;</td>
        
    </tr>
   <tr>
    <td width="10" background="Imagenes/line_fondo.jpg">&nbsp;</td>
    <td width="250" "></td>
    	<td  valign="top" align="left">
        <p style="color:#555555; font-family:Tahoma; font-size:14px">(*)Numero De Documento:</p>
    	</td>
        <td>
        <input name="cc_documento_us1" id="cc_documento_us1" class="celda" type="text"  value="" />
          <script>var f4 = new LiveValidation('cc_documento_us1');
			f4.add( Validate.Numericality, { onlyInteger: true } );
			f4.add( Validate.Presence ,{failureMessage: "Campo Obligatorio" });</script>
    	</td>
            <td width="10" background="Imagenes/line_fondo_1.jpg">&nbsp;</td>
    </tr>
    <tr>
    <td width="10" background="Imagenes/line_fondo.jpg">&nbsp;</td>
    	<td width="10" "></td>
    	<td valign="top" align="left">
		<p style="color:#555555; font-family:Tahoma; font-size:14px">(*)Direccion Correspondencia:</p>
        </td>
        <td>
		<input name="direccion_us1" id="direccion_us1" class="celda" type="text"   value="" onblur="aMayusculas(this.value,this.id)" />
		 <script>var f4 = new LiveValidation('direccion_us1');
			f4.add( Validate.Length, { minimum: 10 } );
			f4.add( Validate.Presence ,{failureMessage: "Campo Obligatorio" });</script>
    	</td>
	     <td width="10" background="Imagenes/line_fondo_1.jpg">&nbsp;</td>
    </tr>
    <tr>
    <td width="10" background="Imagenes/line_fondo.jpg">&nbsp;</td>
    	<td width="250" "></td>
    	<td valign="top" align="left">
		<p style="color:#555555; font-family:Tahoma; font-size:14px">(*)Telefono:</p>
        </td>
        <td>
		<input name="telefono_us1" id="telefono_us1" class="celda" type="text"   value=""/>
		 <script>var f4 = new LiveValidation('telefono_us1');
			f4.add( Validate.Numericality, { onlyInteger: true } );
			f4.add( Validate.Length, { minimum: 7 } );
			f4.add( Validate.Presence ,{failureMessage: "Campo Obligatorio" });
			</script>
    	</td>
	     <td width="10" background="Imagenes/line_fondo_1.jpg">&nbsp;</td>
    </tr>
<tr>
    <td width="10" background="Imagenes/line_fondo.jpg">&nbsp;</td>
    	<td width="250" "></td>
    	<td valign="top" align="left">
		<p style="color:#555555; font-family:Tahoma; font-size:14px">(*)Correo Electronico:</p>
        </td>
        <td>
		<input name="mail_us1" id="mail_us1" class="celda" type="text"   value=""/>
		 <script>var f4 = new LiveValidation('mail_us1');
			f4.add( Validate.Email );
			f4.add( Validate.Presence ,{failureMessage: "Campo Obligatorio" });
			</script>
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	     <td width="10" background="Imagenes/line_fondo_1.jpg">&nbsp;</td>
    </tr>
    
    <tr>
    <td width="10" background="Imagenes/line_fondo.jpg">&nbsp;</td>
    	<td width="250" "></td>
    	<td valign="top" align="left">
        <p style="color:#555555; font-family:Tahoma; font-size:14px">(*)Departamento:</p>
    	</td>
        <td>
       <select name='selDepartamento' id='selDepartamento' class="celda" style="font-size:14px;font-family:Tahoma" onchange='document.formCNTV.submit();' >

                
		</select>
		 </td>
        <td width="10" background="Imagenes/line_fondo_1.jpg">&nbsp;</td>
    </tr>
    <tr>
    <td width="10" background="Imagenes/line_fondo.jpg">&nbsp;</td>
    	<td width="250" "></td>
    	<td valign="top" align="left">
        <p style="color:#555555; font-family:Tahoma; font-size:14px">(*)Ciudad (Municipio):</p>
    	</td>
        <td>
		<input name="mail_dd" id="mail_dd" class="celda" type="text"   value=""/>
		 <script>var f4 = new LiveValidation('mail_dd');
			f4.add( Validate.Numericality, { onlyInteger: true } );
			f4.add( Validate.Presence ,{failureMessage: "Campo Obligatorio" });
			</script>
    	</td>
	     <td width="10" background="Imagenes/line_fondo_1.jpg">&nbsp;</td>
    </tr>
    <tr>
    <td width="10" background="Imagenes/line_fondo.jpg">&nbsp;</td>
    	<td width="250" "></td>
    	<td align="left" valign="top">
    	<p style="color:#555555; font-family:Tahoma; font-size:14px">(*)Tipo de Queja:</p>
    	</td>
        
    	<td>
		<input type="checkbox" name="queja1" class="celda" value="sel" > 
		Inasistencia T&eacute;cnica. Posibilidad acceso canales radiodifundidos<br>
		<input type="checkbox" name="queja2" class="celda" value="sel" > 
		Imposibilidad T&eacute;cnica prestar servicio<br>	
		<input type="checkbox" name="queja3" value="sel" > 
		Facturaci&oacute;n y cobros injusto, compensaci&oacute;n por no prestar servicio<br>
		<input type="checkbox" name="queja4" value="sel" > 
		Atenci&oacute;n a los suscriptores PQR <br>
		<input type="checkbox" name="queja5" value="sel" > 
		Reporte a centrales de riesgo <br>		
		<input type="checkbox" name="queja6" value="sel" > 
		Incumplimiento contrato de suscripci&oacute;n  PQR <br>
		<input type="checkbox" name="queja7" value="sel" > 
		Otro<br>
		
			
    	<textarea name="queja" id="queja" cols="40" rows="1"  class="celda" onblur="aMayusculas(this.value,this.id)">
        </textarea>
    	</td>
            <td width="10" background="Imagenes/line_fondo_1.jpg">&nbsp;</td>
    </tr>
    
    <tr>
    <td width="10" background="Imagenes/line_fondo.jpg">&nbsp;</td>
    	<td width="250" "></td>
    	<td align="left" valign="top">
    	<p style="color:#555555; font-family:Tahoma; font-size:14px">(*)Mensaje:</p>
    	</td>
        
    	<td>
    	<textarea name="descripcion" id="descripcion" cols="40" rows="6"  class="celda" onblur="aMayusculas(this.value,this.id)">
        </textarea>
    	</td>
            <td width="10" background="Imagenes/line_fondo_1.jpg">&nbsp;</td>
        </tr>
     
    <tr align="center">
    <td width="10" background="Imagenes/line_fondo.jpg">&nbsp;</td>
    	<td width="250" "></td>
    <td align="center" colspan="2">
    	<input name="btnComision" id="btnComision" type="submit" value="Imponer Queja" class="boton" /> 
    </td>
    <td width="10" background="Imagenes/line_fondo_1.jpg">&nbsp;</td>
    </tr>
    </table>
    </form>

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          <area shape="rect" coords="11,16,60,47" href="http://www.telecaribe.com.co/" target="_blank" />
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        <div class="azul">
          <div align="center">Comisi&oacute;n Nacional de Televisi&oacute;n Calle 72 # 12 - 77 - Linea gratuita 018000 919796 - PBX: (571) 5953000. Horario de atenci&oacute;n de lunes a viernes de 8 a.m.a 5 p.m. - Para contactarse con nosotros escribanos a<a href="mailto:info@cntv.org.co" class="rojo"> info@cntv.org.co </a>- Copyright &copy;  - Todos los derechos reservados - Dise&ntilde;o y desarrollo: Oficina de  Comunicaciones y Prensa CNTV</div>
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